eCQM Title

Potential Opioid Overuse
eCQM Identifier (Measure Authoring Tool) 460 eCQM Version number 1.2.000
NQF Number Not Applicable GUID 442edef2-7347-4080-988f-16c9d1998803
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Developer The Lewin Group
Endorsed By None
Description 
Percentage of patients aged 18 years or older who receive opioid therapy for 90 days or more with no more than a 7-day gap between prescriptions with a daily dosage of 90 morphine milligram equivalents (MME) or more
Copyright 
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.
  
CPT(R) contained in the measure specifications is copyright 2004-2018 American Medical Association. LOINC(R) copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organisation. ICD-10 copyright 2018 World Health Organization. All Rights Reserved.
Disclaimer 
These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring Proportion
Measure Type Process
Stratification 
None
Risk Adjustment 
None
Rate Aggregation 
None
Rationale 
More than 100 million people in the United States suffer from chronic pain (Institute of Medicine, 2011). An estimated 259 million opioid prescriptions to manage pain were written in the United States in 2012, approximately half of which were written by primary care providers (Cox et al., 2018). From 2000 to 2015, mortality from opioid-specific drug poisoning in the United States tripled, resulting in a reduction in life expectancy for non-Hispanic, white individuals (Dowell, Haegerich, & Chou, 2016).

Although all opioids can be dangerous, chronic use of opioids at high doses are more likely to result in fatalities and other adverse drug events (Edlund et al., 2014; Morasco et al., 2010; Atluri, Akbik, & Sudarshan, 2012; Paulozzi et al., 2014). Recent guidelines recommend that providers use the lowest dose possible when initiating opioid therapy and that they carefully justify prescribing doses above 90 morphine milligram equivalents (MME) per day, considering the benefits and harms of the dose they select (Dowell et al., 2016).

In a large cohort study of almost 18 million commercially insured patients in the United States, about 15 percent of opioid recipients received a daily dose of 100 MME or higher, and 12 percent received more than a 90-day supply (Liu et al., 2013).
Clinical Recommendation Statement 
The Centers for Disease Control and Prevention's (CDC) Guideline for Prescribing Opioids for Chronic Pain—United States, 2016 (Dowell et al., 2016) states:

"When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to [greater than or equal to] 50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to [greater than or equal to] 90 MME/day or carefully justify a decision to titrate dosage to [greater than or equal to] 90 MME/day."

"Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids."
Improvement Notation 
A lower rate indicates better quality
Reference 
Atluri, S., Akbik, H., & Sudarshan, G. (2012, July). Prevention of opioid abuse in chronic non-cancer pain: An algorithmic, evidence-based approach. Pain Physician, 15(3), ES177-ES189.
Reference 
Cox, N., Tak, C. R., Cochella, S. E., et al. (2018, January). Impact of pharmacist previsit input to providers on chronic opioid prescribing safety. Journal of the American Board of Family Medicine, 31(1), 105-112.
Reference 
Dowell, D., Haegerich, T. M., & Chou, R. (2016, March). CDC guideline for prescribing opioids for chronic pain—United States, 2016. Recommendations and Reports, 65(1), 1-49.
Reference 
Edlund, M. J., Martin, B. C., Russo, J. E., et al. (2014, July). The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain. Clinical Journal of Pain, 30(7), 557-564.
Reference 
Institute of Medicine. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Retrieved from http://www.nationalacademies.org/hmd/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx
Reference 
Liu, Y., Logan, J. E., Paulozzi, L. J., et al. (2013, August). Potential misuse and inappropriate prescription practices involving opioid analgesics. American Journal of Managed Care, 19(8), 648-658.
Reference 
Morasco, B. J., Duckart, J. P., Car, T. P., et al. (2010, December). Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain, 151(3), 625-632.
Reference 
Paulozzi, L. J., Zhang, K., Jones, C. M., et al. (2014, May–June). Risk of adverse health outcomes with increasing duration and regularity of opioid therapy. Journal of the American Board of Family Medicine, 27(3), 329-338.
Definition 
Long-term opioid therapy is defined as opioid use for 90 consecutive days or more (Dowell et al., 2016).

High-dose usage is defined as at least a 90 MME dosage per day (Dowell et al., 2016).

Morphine Milligram Equivalent (MME) is a value assigned to opioids to represent their relative potencies. For this measure, the MME is determined by calculating the prescribed maximum daily dose by the Center for Disease Control and Prevention's (CDC) conversion factors.

Cumulative Medication Duration (cmd) is the total number of calendar days that an individual has an active medication during a specific period. This period includes multiple prescriptions with gaps in between that are 7 days or less.
Guidance 
Abbreviations used in this measure:
MME - morphine milligram equivalents (used in measure narrative and logic) 

cmd - cumulative medication duration (used in measure logic)

scripts - prescriptions (used in the measure logic)

meds – medications (used in the measure logic)   

Explanation of timings used in this measure:
period - time frames referring to the relevant period of the opioid medication or encounters during the measurement period and indicating the length of time between prescriptions (used in the measure logic)  

Calculating the opioid timeframe is accomplished by either using the start and end dates for the prescription or if the end date is not provided for the prescription, the day supplied attribute is used to calculate the end date (e.g., start date plus days supplied- start date February 1 and days supplied 7 therefore the end date is February 8). 

This measure allows for up to 7 days between prescriptions for long-term opioid users. If a patient has a gap between prescriptions of 7 days or less but takes one or more opioids listed below for at least 90 days, he or she will still be included in the measure’s denominator. In the logic, the approach to find the periods in which the patient has opioid medications, determines the gaps of more than 7 days to provide the boundaries in which to create a list of periods with allowed gaps.   

For this measure, the numerator applies to patients in the initial population with a 90-day or more supply of opioids with no more than a 7-day gap between prescriptions of 90 MMEs or higher per day.

The daily dosage is derived by multiplying the single dose administration by the frequency for the day. The highest possible daily dosage will be used for the prescription period (e.g., Prescription is for 10 mg tabs; take 1 -2 tabs QID (four times a day) as needed for pain. The range would be 0 mg to 80 mg per day. 80 mg would be used for each day of that prescription period).

The numerator criteria of this measure are satisfied for all patients in the initial population with a 90-day or longer supply of the following specified opioids at a 90 MME or more average daily dose:
-Butorphanol
-Codeine
-Dihydrocodeine
-Fentanyl
-Hydrocodone
-Hydromorphone
-Levorphanol
-Meperidine (Pethidine)
-Methadone
-Morphine
-Nalbuphine
-Opium
-Oxycodone
-Oxymorphone
-Pentazocine
-Tapentadol
-Tramadol

The omission of buprenorphine is intentional.

MME for each opioid used in measure calculation is based on conversion factors provided by the CDC. Providers can access these values through CDC’s opioid guideline mobile app (available here for download: https://www.cdc.gov/drugoverdose/prescribing/app.html).  For more details on how to calculate daily dose, please review CDC's "Guideline for Prescribing Opioids for Chronic Pain--United States, 2016;" a two-page quick reference guide is also available here: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf

Current technical specifications require use of a lengthy opioid data library within this measure to capture specific drug ingredient information.The opioid data library is used in several measures and as such in order to harmonize,  there are intentional discrepancies between the  opioid data library and the opioid medication value set used in the measure. The differences do not effect the measures' intent. Efforts to resolve this technical limitation are being explored for future versions of this measure.
Transmission Format 
TBD
Initial Population 
Patients 18 years of age and older prescribed a 90 day or longer supply of opioids with 7 days or less between each opioid prescription and who have a qualifying encounter during the measurement period
Denominator 
Equals Initial Population
Denominator Exclusions 
Patients receiving palliative or hospice care or having a diagnosis of sickle cell disease during or overlapping the measurement period.

Patients with a diagnosis of cancer one year or less prior to or during the measurement period.
Numerator 
Patients with a daily dosage of 90 morphine milligram equivalents or more prescribed during the measurement period
Numerator Exclusions 
None
Denominator Exceptions 
None
Supplemental Data Elements 
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents


Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables


Measure Set